Has Bioterrorism Preparedness Improved Public Health?

n anticipation of future terrorist attacks, the nation has been focused on emergency preparedness,1 including threats to public health and the ability of communities to respond to them. The Center for Studying Health System Changes (HSC) recent site visits to 12 nationally representative communities found early benefits to public health due to heightened attention to bioterrorism preparedness: more visibility and credibility for public health, stronger public health infrastructure and improved communication and coordination across sectors. Modest negative effects included staff diversions and delays in some program implementation. As the site visits continued from fall 2002 into 2003, concerns grew that the federal smallpox vaccination program was diverting resources from such traditional public health activities as routine immunizations, health promotion and screening.

National Focus on Public Health Preparedness

ince the terrorist attacks of Sept. 11, 2001, and the
subsequent anthrax incidents, strengthening the ability of public health to
respond to bioterrorism emergencies has been at the forefront of national health
policy. On Jan. 10, 2002, President Bush signed a bill that directed more than
$1 billion to states to improve public health preparedness. 2

The majority of funds is being awarded based on state and local plans that
target areas identified by the Centers for Disease Control and Prevention (CDC)
and the Health Resources and Services Administration (HRSA). The CDC focus areas
include preparedness planning and readiness assessment, surveillance and epidemiology
capacity, laboratory capacity, health alert network/communications, risk communication
and health information dissemination and education and training. 3
HRSA guidelines focus on improved hospital readiness for bioterrorism. Continued
federal funding for 2003 totals $1.4 billion for states and localities for smallpox
vaccination efforts as well as other preparedness activities. 4,5

During site visits to 12 nationally representative metropolitan communities6
in 2002-03 as part of HSCs Community Tracking Study (CTS), researchers interviewed
state and local health department officials, first responders,7
hospital executives and others about bioterrorism preparedness efforts and the
effects on core public health activities. These activities include traditional
functions performed by local health departments such as health promotion, routine
immunizations and infectious disease investigations. Generally, respondents
indicated that national priorities of bioterrorism preparedness have enhanced
public health preparedness, with positive effects on core public health functions,
through early improvements to basic infrastructure.

Early Benefits

he national focus on bioterrorism preparedness, combined
with the distribution of federal funds, has had positive effects on local public
health systems. For the most part, federal priorities match longstanding objectives
for strengthening public health capacity. The new funding enables communities
to develop the building blocks needed to respond to varied disaster scenarios,
including bioterrorism. Community leaders said the infrastructure for bioterrorism
preparedness will have multiple uses that benefit broader public health activities,
especially those related to infectious disease control.

The four key areas strengthened by bioterrorism preparedness efforts at
the local level include: 1) increased awareness of the importance of public health;
2) improved relationships across communities and federal, state and local agencies;
3) development and upgrade of public health infrastructure; and 4) enhanced readiness
planning and assessment (see Table 1).

Prominence of Public Health. Heightened attention on bioterrorism
preparedness has put public health in the spotlight, increasing awareness of its
importance in communities. Senior public health officials are now taking leading
roles in disaster response in contrast to their more tangential role in the past.
A Seattle health official said increased visibility of public health would allow
the city to engage the community in other public health concerns, including West
Nile virus, diabetes and obesity. A Florida official believed that the increased
attention to bioterrorism preparedness has enhanced the states work, allowing
it to hire more epidemiologists and work with partners on routine immunizations.
Other communities reported more visibility of public health in the media and greater
awareness in the state legislature.

Collaboration. Bioterrorism preparedness efforts have
led to improved collaboration between local organizations and government agencies
that extends to broader public health and safety functions, including infectious
disease control and response to food-borne illness, hazardous waste spills and
natural disasters. Before Sept. 11, public health agencies often had limited contact
with other community entities, such as emergency management, law enforcement,
fire departments, hospitals and physicians.

The attacks highlighted the need for much closer communication and coordination
across all sectors. Differences in organizational cultures, terminology and approaches
to emergency response have been barriers to effective interagency collaboration,
but the imperatives of bioterrorism preparedness required these agencies to understand
each others roles and capabilities in the case of a disaster. As a result, stronger
personal relationships have developed between public health officials and their
counterparts in medical care and public safety. For example, in Lansing, the local
emergency planning commission that coordinates preparedness planning now includes
community-wide representatives and has created new linkages with the medical community.

Relationships among federal, state and local agencies also have improved. In addition to the CDC and HRSA, state and local interactions increased with other federal agencies, such as the Federal Bureau of Investigation. Many local health officials say their state counterparts have provided valuable resources and expertise. A number of states have established regions through which local organizations work together. Local officials also noted the importance of states roles in allocating federal funds, although some complained about the process for distributing funds to local agencies. For example, the Seattle public health department disagreed with the state of Washingtons decision to distribute new federal funds evenly across 10 regions. City officials argued for a greater proportion because of the perceived higher threat level and because more than one-third of the states employed population works in Seattle.

Infrastructure. Infrastructure upgrades were widespread across
the 12 sites. Communities significantly improved communication technologies, with
local officials frequently touting the importance of creating highly reliable
and redundant telephone and radio systems. For example, in Orange County, Calif.,
paramedic radios have been upgraded to connect ambulance, fire, police and hospitals.
In northern New Jersey, all hospitals received special radios for emergency communications.
In general, upgrades in communication systems are expected to improve responses
to terrorist events and other public health emergencies, such as floods or earthquakes.

Most communities are building information and disease reporting systems that will enhance surveillance and provide rapid communications with the medical community. For example, the Miami-Dade County Health Department is developing a Web-based data system, in which hospitals will participate, that will speed tracking of communicable diseases. Improvements in disease reporting and surveillance systems strengthen the response to naturally occurring disease outbreaks, such as severe acute respiratory syndrome (SARS).

Some markets began preparation before Sept. 11. In planning for the World Trade
Organization protests in 1999, Seattle placed a syndromic surveillance system
in hospitals that tracks sudden increases in the incidence of symptoms in a
population that might signal a bioterrorist or natural public health emergency,
without identifying a particular pathogen. 8 Similarly,
using federal funds received before Sept. 11, Boston implemented a volume-based
reporting system—an automated system that tracks the daily volume of acute
care cases in hospitals across the city and compares them to historical averages—and
is now working to upgrade to a syndromic system.

Efforts to improve public laboratory capacity are underway in several communities.
For example, in Little Rock, the state is building a new lab and has upgraded
another facility to be able to identify and handle a wider array of pathogens.
In response to a previous anthrax scare, the Marion County Health Department
in Indianapolis invested its own funds to improve laboratory capacity in 2001.
Greater capacity will allow for more rapid identification of disease agents,
thereby improving overall public health.

Readiness Planning and Assessment. Across the 12 communities,
local leaders reported improved readiness to respond to different kinds of disasters,
including public health threats. Some communities were further ahead in emergency
preparedness efforts than others, due to previous experience in planning for adverse
events or natural disasters. Cities that commonly host large events, such as the
Indy 500, or have nuclear power plants or similar potentially high-risk facilities
nearby reported a higher level of preparation. Most sites have held training sessions
and simulated disasters to test their emergency response. For example, the Arkansas
Department of Health collaborated with a local community to test its response
to smallpox by administering flu shots on a single day. Training public health
officials, physicians and hospitals in epidemiology and detection of common bioterrorist
agents has also increased. In general, however, education of the workforce across
all sectors was viewed as a continuing challenge. Most recently, the threat of
SARS has provided a real test of readiness. One Massachusetts official reported
that the state mounted a more efficient response to SARS as a result of its preparedness
efforts.

Table 1
Positive Effects of Bioterrorism Preparedness

Positive Effects

Examples

Prominence of Public Health

Seattle: greater visibility will help engage the community
in other public health concerns

Miami: increased attention has helped Florida in hiring
epidemiologists and working with partners on routine immunizations

Collaboration

Lansing, Mich.: competing hospitals have pulled together
through local emergency planning commission

Greenville, S.C.: relationships improved among federal,
state and local agencies, the medical community and public safety

Infrastructure

Northern New Jersey: hospitals received special radios
for emergency communications

Boston: city implemented an automated system to track
daily volume of acute care cases in hospitals

Readiness Planning
and Assessment

Little Rock, Ark.: state tested response to smallpox
by administering flu shots on a single day

Modest Negative Effects but Increasing Anxiety

esponses to questions about the effects of bioterrorism preparedness on core public health activities changed over the period of HSCs site visits. In late 2002, the most
common complaint from local health departments and hospitals was the diversion of staff to work on preparedness planning and to attend meetings and training sessions. Staff reallocations were frequent, and some concern was expressed that agency staff were being stretched thin. One local health department reported that implementation of an obesity and diabetes prevention initiative was delayed due to the focus on preparedness planning, but overall core public health activities had not yet suffered.

By early 2003, however, concern grew over the ability to maintain core public health services while focusing on bioterrorism preparedness as it evolved from general infrastructure development to specific threat response. More complaints were heard about the burden of implementing a federal smallpox vaccination program without sufficient funding.

The federal government authorized states to begin the first phase of the smallpox
vaccination program—planning for and inoculating health workers—in
late January 2003. According to a survey by the National Association of County
and City Health Officials, 79 percent of local health departments reported that
smallpox vaccination planning had negatively affected other bioterrorism preparedness
activities.9 Also, about half had deferred, delayed
or canceled other core public health programs.

Before January 2003, few respondents in CTS communities mentioned the effects
of smallpox planning on other public health activities. Some local officials
in Lansing and Greenville described smallpox planning as a distraction, but
it had not directly undermined other programs. Instead, impending state budget
cuts were the foremost concern of local officials across markets (see box).

By spring 2003, local officials said they expected the smallpox vaccination program to divert critical resources from core public health activities. For example, in Orange
County, if nurses werent giving vaccinations, they would be working in clinics or making home visits. Similarly, public health nurses in Boston and Syracuse were being shifted
to smallpox efforts, detracting from disease prevention programs. In addition to the costs in lost staff time, respondents reported the expense of training health care workers and
screening candidates for smallpox vaccination as a growing problem. In several sites, insufficient funding resulted in the diversion of resources targeted for infrastructure and other public health programs to smallpox vaccination planning. In May 2003, the federal government announced the release of $100 million to help states with smallpox preparedness, but it is too early to see if this will provide sufficient relief.

Budget Cuts Hit Core Public Health Activities

ndependent of preparedness efforts, state and local budget cuts were viewed in most sites as a major threat to core public health activities. Most states faced budget gaps for
fiscal year 2003, with an even bleaker outlook for fiscal year 2004. In Cleveland, a local health official reported state budget cuts in direct treatment, immunizations and case management. Respondents in Syracuse, Boston and Seattle expressed concern that proposed budget cuts would impair local health department activities such as tuberculosis and West Nile virus prevention, cancer screening and childhood immunizations. In fact, in King County, where Seattle is located, public health spending per person has dropped 33 percent, from $21.34 six years ago to $14.35 today. 10 While new federal bioterrorism preparedness funds are allowing states and localities to build up public health capacity
for disease surveillance and response, these funds cannot supplant other state or local expenditures, leaving more traditional public health programs, like sexually transmitted
disease clinics, in jeopardy.

Outlook for Public Health

he first wave of federal guidance and funding for bioterrorism preparedness appears to have strengthened such basic public health building blocks as disease surveillance, laboratory capacity and communication systems while also strengthening working relationships across local agencies and organizations. As a result, public health agencies in
the 12 CTS communities were able to decide how best to approach the federal focus areas and invest new resources to improve their ability to respond to emergencies of any kind,
including terrorism.

In contrast, the federal smallpox program is much more restrictive and targeted,
focusing on a single biological agent and a federally defined response (i.e.,
inoculating health workers). The program caused local health officials to express
concern that the highly specific smallpox activities are less likely to strengthen
overall public health capacity and—especially if funding is inadequate—are
more likely to detract from ongoing public health preparedness and traditional
prevention efforts.

Given the likelihood that bioterrorism will remain a high-profile issue, states
and localities will likely need ongoing dedicated funds to build and maintain
bioterrorism preparedness capacity. Without continuing support, activities that
require more than a one-time investment, such as training the health care workforce
and upgrading information technology, will fall short.

With the wide range of potential threats to public health, respondents indicated
that funding and guidelines for preparedness efforts should focus on broad infrastructure
changes that support multiple activities, without detracting from traditional
public health prevention and promotion efforts. Federal policy makers appear to
reflect this perspective as the most recent CDC guidance asks states and localities
to better integrate smallpox planning into ongoing preparedness efforts. 11
Future policy decisions regarding bioterrorism preparedness will have to address
the consequences of targeted mandates on states and localities and their effects
on core public health functions, especially as budget crises threaten other public
health funding.

Notes

1.

"Emergency preparedness" refers to a communitys efforts to
prepare for emergencies of any type, natural or intentional. "Public
health preparedness" refers to the part of emergency preparedness focused
on public health threats. "Bioterrorism preparedness" refers to
a communitys efforts to prepare for terrorist events, including biological,
chemical or nuclear.

2.

U.S. Department of Health and Human Services, press release, "Federal
Funds for Public Health Infrastructure Begin to Flow to States" (Jan. 25,
2002).

3.

Centers for Disease Control and Prevention, Guidance for Fiscal Year 2002
Supplemental Funds for Public Health Preparedness and Response for Bioterrorism,
Announcement Number 99051-Emergency Supplemental (Feb. 15, 2002).

Additional funding for emergency and public health preparedness originated
before Sept. 11, such as the federal Metropolitan Medical Response System
and Turning Point, an initiative of The Robert Wood Johnson Foundation and
the W. K. Kellogg Foundation.

6.

HSC interviews community leaders about how the health care system is changing
in the following 12 metropolitan areas with populations over 200,000: Boston;
Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock,
Ark.;Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle;
and Syracuse, N.Y.

7.

First responders include fire officials, police, emergency medical services
and others that respond to emergencies.

8.

Salinsky, Eileen, Will the Nation Be Ready for the Next Bioterrorism Attack?
Mending Gaps in the Public Health Infrastructure, National Health Policy
Forum, Issue Brief No. 776 (June 12, 2002).

9.

National Association of County and City Health Officials, Impact of Smallpox
Vaccination Program on Local Public Health Services, Research Brief No.
9 (February 2003).

Centers for Disease Control and Prevention, Continuation Guidance for Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism—Budget Year Four, Program Announcement 99051 (May 2, 2003).